Adults with low health literacy have been shown to have worse self-care and worse health outcomes. While few studies have looked at the relationship between parental health literacy and the health of children, studies have documented that parents are likely to incorrectly dose their children's medications. The impact of such errors is likely to be greatest for children with chronic disease, requiring complicated medication regimens. The Teach-Back technique, an iterative communication strategy in which a health care provider checks for understanding by asking the patient (or caretaker) to repeat the instructions she/he has been given, has been proposed by experts as a useful tool for improving understanding of instructions by clients with low health literacy. While there is promising observational data suggesting that the technique is effective and does not add time to the doctor-patient visit, we are aware of no published experimental studies that test the effectiveness of the Teach-Back technique. Because this technique is a potentially inexpensive intervention that can be promoted for wide use, the principal investigator's major research goal is to design and conduct a multi-center randomized controlled trial that will test the effectiveness of the use of the Teach-Back technique with caretakers who have low health literacy - in the context of childhood asthma, the most common chronic condition encountered in pediatrics. In order to design such a study, we propose the current exploratory protocol that will inform a future R01 application to conduct the larger trial. The proposed exploratory study will consist of three phases, and three corresponding specific aims. Specific Aim 1: To develop a content-valid index of Teach-Back fidelity, and to evaluate its inter-rater reliability. This will be achieved through convening of an Expert Panel who will develop, refine, field-test, and revise the measure until content validity is achieved. Specific Aim 2: To obtain preliminary estimates of the effectiveness of a Teach-Back intervention, and the possible mechanisms through which it works. Using a quasi-experimental design, a comparison group of caretakers of children with asthma before physician training in Teach-Back will be compared to a group recruited after the Teach-Back training. Primary Outcomes will include: caretaker understanding of medication instructions, caretaker adherence to child's prescribed asthma medications. Secondary Outcomes: change in child asthma control and lung function. We will also collect information on possible mediating variables between Teach-Back and adherence, including: caretaker self-efficacy, satisfaction with care, and beliefs about medication. Audio-taping of physician-caretaker encounters will allow measurement of doctor-patient communication style using the Roter Interaction Analysis System, which may reveal other potential mediators. Specific Aim 3: To obtain qualitative data regarding the experience of physicians and caretakers with Teach- Back and their thoughts on the possible mechanisms of its contribution to outcomes. This will be achieved through the use of focus groups. PUBLIC HEALTH RELEVANCE: By creating a Teach-Back fidelity Index, we will provide a critical tool for future work that seeks to prove a causal pathway between Teach-Back and improved health outcomes. If Teach-Back is effective, widespread use has the potential to reduce medication errors, improve adherence, and reduce disease morbidity. While this study focuses on the parents of children with asthma, the estimates of effect of Teach-Back can inform work with other populations that rely on the literacy skill of surrogate decision makers or caretakers - for example the elderly or disabled, with a variety of chronic medical conditions, including diabetes, hypertension and cardiovascular disease.